| NPI | 1790231223 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-06646) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NC 0010-06646) |
| Enumeration Date | 2016-08-25 |
| Last Update Date | 2026-03-17 |